7101 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LD1 NG PROJECT IDENTIFICATION PERMIT NUMBER
BUILDING APPLICATION & PERMIT
I -4( s 7101 '
BUILDING -ELECTRICAL-PLUMBING-MECHANICAL
rvE 'S PLAN CHECK VALIDATION
NAME OTY. ELECTRIC PERMIT FEE
. ONE
rvamsRr UTLETS-SWITCHES-RECEP
5.00 1.
�- u=1166 elm IF,:uc.No. LIGHTING FIXTURES '5.00/1.00
CONTFAI!TOFFSADDRESS APPLIANCES-RESIDENTIAL 4.00
ONE" PANELS 5.00 DATE OF APPLICATION
OR
o SIGNS 6.00 ~• PLANCHECK FEE P.C.NO.
ENGINEER
_IC,.0 SIGNS TRANS. 3.00 i
AARCH.OR DDRESS NG. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
I'^
ZIP TEMP.METER OR POLE INS. 15.00 /
AvvucANrs MOTORS SEE FEE SCH.
ADDRESS
SERVICE CHANGE 10.00
o¢ z
F 00 LICENSE CONTRACTORS DECLARATION
Q o 1 hereby affirm that 1 am licensed under provisions of Chapter 9 I A E DATE
w a ac (commencing with Section 7000)of Division 3 of the Business and BLDG. E CT. PLG. MECH.
r N z Professions Co 1 my license is in full force and effect.
z o,�- License Class_ Lie-Plural
6 w w Dam__��Z Contractor
-~ J
S BUI DING RMIT
ce Q w ¢ O Ii R-BUIL)ER DEC AI'ION INFORMATION
odea MISC.- REFER TO ORD
g LL m I hereby affirm that I am exempt from the Contractor's License VALUATION S/FT.
r LL m j Law for rise following reason.(Sec.7031.5,Businessand Professimts PERMIT ISSUANCE 6.00
Code:Any city or county which"uimsa permit to construct
2 Q 0 improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
-o u requires the applicant fur such permit to file a signed statement that TOTA / ER IT TO
'a w m m he is licensed pursuant to the provisions of the Contractor's License
F i>- Law(Chapter 9(commencing with Section 7000)of Division 3ofthe
g- - a Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
o the hasis for the alleged exemption.Any violation of Sc,ti.D 7031.5 ST I£S TYPE CONSTR.
m by any applicant ho.permit subjects the applicant toa civil penalty
of not more than five hundred dollars C5500).): ALTER-DRAIN&VENT-WATER (EA.14.00
❑ I,as owner of the property,or my employees with wages asggCK FLOW PROTECT.DEVICE 2.00 OC UP NTS
their sole compensation,will do the work,and the structure is not
intended or offered for sale(Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 4.00
Code:The Contractor's License Law dues not apply to an owner of i
Property who builds or improves thereon.and who does such work 0, FIXTURES-PER TRAP 4.00 / s0.R .F EfrD RARERTLA AGE
himself or through his own employees,provided that such improve Cp
ments are not intended or offered for sale.If,however,the building GAS-EA.SYSTEM-11NC.4 OUTLETS 4.00
D
r improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4(EA.) 1.00 BUILDING USE
builder will have the burden of proving that he did not build or im-
prove for purpose ofsale.). INDUSTRIAL WASTE INTER. 20.00
/ ❑ I,as owner of the property,am exclusively contracting with ❑ ❑ ❑ ❑
licensed cmnrucmrs to construct the project(See. 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 5.00 ASSESSORSPARCELNO.
an Professions Code- [he Contractor's License Law does not apply ,
to an owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(Eq.) 1.00
contracts forsuch projeas with a c(ntradop%)licensed pursuant la -
theContixclorsLicenseLaw. SEWER-SANITARY-STORM EA.200ft/B.00 / RACT NO. PARCEL NO.
-❑ Ion czenrpt under See ,B.&PL.for this WATER HEATER W/VENT 4.00
reason
Owner Dale WATER SYSTEM 4.00 A AT ACC.FILE NO.
WORK BRpSS'��CffOM��PPFNSAT1ON DECLARATION WATER TREATING EQUIP. 4.00 N
I b,4ni%lMaF.-b-1 ZCL?�Ic of consent tosell-insure. ZONING
or a certificate of Workers'Compensation Insurance,or a certii'ied ENG.SITE NO.
copy thercnGSec.3800,Lab.C.I.
Policy No. - Company _b, [A
O ❑ Ce rlifmdcopy'is hereby DR-RIN FIRESPRINK ENERGY T-24
Z 2• Ce reified 'o Y iz filed with the city inspection division.
O AI,IL I,: MISC.- REFER TO ORD. Y ❑ N❑ Y ❑ No
cc'N CIiRT A 'G Of E:EA I'1 N OM WORKERS' PERMIT ISSUANCE 6.00 - FLOOD ZONE A.L.0 c.
LU > COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG. '
CL O ('f his Section need not be completed if the permit is for one TOTAL / Y❑ N❑ Y ❑ N❑
::) 2 hundred dollars IS 100)or less.)
U O I certify that in the performance of the work for which this per- OTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL F nllt Is issued, I droll not employ any person in any manner so as to
O W become subject to the Workers'Compensation Laws of California. BUILDING (�
ED Dam Applicant ALTER OR ADD TO MECH. 4.00
>_ to NOT ICE '1'O APPLICANT. If,alter makins this Certificateof nix
Z eruption,you should become subject to the Workers'Compensation APPLIANCE 4.00 / PLAN CHECK
provisions of the Labor Code, you must forthwith comply with FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10MC.F.M.) 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 101100C.F.M.) 5.00 SEISMIC FEE
1 1 hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 2.00
the e,h...marIce of the work fun which this permit is isscJ(Sec. MICROFILM
3097,Civ.c.). HEATING UNIT(TO 100,000 B.T.U.) 4.00 /
Lender's Name /7/Q•s �[IIY.17�
Lenders Address-�' -� -r-e-� HEATING UNIT(OVER 100,000 B.T.U.)7.50 ELECTRIC /
I certify that have reudil ap lir non an slate that f" fla ve VENTILATION FAN (SINGLE) 3.00 /
. information n correct. I agree to comply with all city and county BOILER-COMP(3 H.P.or 100,000 B.T.U.) 4.00 PLUMBING �
ordinances and state laws relating m building construction, and
hereby authorize representatives of this city to enter upon the BOILER-COMP(Over t00,0008TU)SEE FEE SCH. MECHANICAL
above-mentioned properly for inspection purposes. /
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which CONST.TAX
may in any way accrue against said City in consequence of the PERMIT ISSUANCE 3.00 /
glinh oflhis JacmtMECH.CONT.': LIC.NO. MECH.
/ TOTAL TOTAL 1D
_ anri�o�ontrnac[I 2/27 sr"
Sl�rratu're'o'f Ffp�icanC'Con rt actor ate
INSPECTOR COPY